1336647213 NPI number — INTEGRATIVE MEDICINE OF BROOKHAVEN P.C.

Table of content: (NPI 1336647213)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336647213 NPI number — INTEGRATIVE MEDICINE OF BROOKHAVEN P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTEGRATIVE MEDICINE OF BROOKHAVEN P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336647213
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7 LOST MEADOW LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT JEFFERSON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11777-1127
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
59 NESCONSET HWY FL 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT JEFFERSON STATION
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11776-2628
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
646-824-1380
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/25/2018

Additional Information

Authorized Official

Authorized Official Last Name:
KANAKOUDAS
Authorized Official First Name:
DIMOS
Authorized Official Middle Name:
G
Authorized Official Title or Position:
OWNER/MEDICAL DIRECTOR
Authorized Official Telephone Number:
646-824-1380

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  257261 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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